structured analysis, evaluation and report of the

ORIGINAL RESEARCH Open Access

Structured analysis, evaluation and reportof the emergency response to a terroristattack in Wuerzburg, Germany using a newtemplate of standardised quality indicatorsT Wurmb1*, N Schorscher2, P Justice3, S Dietz4, R Schua5, T Jarausch6, U Kinstle7, J Greiner4, G Möldner8, J Müller8,M Kraus9, S Simon6, U Wagenhäuser10, J Hemm11, N Roewer2 and M Helm12

Abstract

Background: Until now there has been a reported lack of systematic reports and scientific evaluations of rescuemissions during terror attacks. This however is urgently required in order to improve the performance ofemergency medical services and to be able to compare different missions with each other. Aim of the presentedwork was to report the systematic evaluation and the lessons learned from the response to a terror attack thathappened in Wuerzburg, Germany in 2016.

Methods: A team of 14 experts developed a template of quality indicators and operational characteristics, whichallow for the description, assessment and comparison of civil emergency rescue missions during mass killing incidents.The entire systematic evaluation process consisted of three main steps. The first step was the systematic data collectionaccording to the quality indicators and operational characteristics. Second was the systematic stratification andassessment of the data. The last step was the prioritisation of the identified weaknesses and the definition of thelessons learned.

Results: Five important “lessons learned” have been defined. First of all, a comprehensive concept for rescue missionsduring terror attacks is essential. Furthermore, the establishment of a defined high priority communication infrastructurebetween the different dispatch centres (“red phone”) is vital. The goal is to secure the continuity of information betweena few well-defined individuals. Thirdly, the organization of the incident scene needs to be commonly decidedand communicated between police, medical services and fire services during the mission. A successful mission tacticrequires continuous flux of reports to the on-site command post. Therefore, a predefined and common communicationinfrastructure for all operational forces is a crucial point. Finally, all strategies need to be extensively trained before the reallife scenario hits.

Conclusion: According to a systematic evaluation, we defined the lessons learned from a terror attack in 2016. Furthersystematic reports and academic work surrounding life threatening rescue missions and mass killing incidents are neededin order to ultimately improve such mission outcomes. In the future, a close international collaboration might help to findthe best database to report and evaluate major incidents but also mass killing events.

Keywords: Terror attack, Mass casualties, Evaluation, Quality indicators, Rescue mission

* Correspondence: [email protected] Emergency and Disaster Relief Medicine, Department ofAnaesthesia and Critical Care, University Hospital of Wuerzburg,Oberdürrbacherstrasse 6, 97080 Würzburg, GermanyFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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BackgroundSystematic descriptions and academic evaluations of civilrescue operations during terror attacks or other lifethreatening mass casualty incidents are urgently needed.After the Paris terrorist attacks, some high-ranking arti-cles, describing the events of the night of the 13th ofNovember 2015, and the “lessons learned” from these at-tacks have been published [1–4].Despite these very important publications, there have

not been any systematic and scientific evaluations of themost recent terror attacks so far. Qualified experts how-ever clearly state the need for such evaluations [5, 6].Systematic reports will allow for the description, assess-ment and comparison of civil emergency rescue opera-tions during terrorist attacks and they may serve as avery important basis in order to define and communi-cate the lessons learned [5–9]. For example the Utojaterror attack was reported systematically according to atemplate of indicators published by Fattah et al. [8].Wuerzburg (Bavaria/Germany) experienced the first of

a series of terrorist attacks and other mass killing eventswithin Germany. A terrorist attacked train passengerswith an axe and a knife on the eve of the 18th of July2016. Four people were seriously injured before the traincame to an emergency halt in the middle of a residentialarea. The emergency stop led to the offender halting theattack and escaping on foot. During his escape he in-jured a 5th person severely with an axe strike. Anotherperson was injured when fleeing the train. The terroristwas later captured by a special police task force and shotin self-defence after attacking the police officers.The evaluation of the rescue mission resulted in the

realisation that a systematic description and academicevaluation of the operation was urgently needed. As afirst step we developed a template of quality indicatorsand operational characteristics, which allow for the de-scription, assessment, reporting and comparison of civilemergency rescue operations during terrorist attacks orshooting rampages [10]. We than started a systematicthree step evaluation process using this template of qual-ity indicators. The result is a systematic report and thedefinition of specific lessons learned from the terroristattack in Wuerzburg.Some models and templates for such systematic de-

scriptions of rescue missions for mass casualty incidentshave been described internationally [7–9]. One of themwas presented by Fattah et al. [8]. Although these tem-plates are very well designed, we decided to define a sep-arate template, which focus on mass killing events andwhich would be better adapted to the German Emer-gency Medical Service’s (EMS) conditions [10]. For ourunderstanding, it would not have been helpful to extendthe existing templates as we wanted to learn more aboutthe special conditions during mass killing events and we

wanted to adapt these lessons learned directly to theGerman EMS System.

MethodsUnder the direction of the subsection “Emergency andDisaster Relief Medicine” of the Department of Anaes-thesia and Intensive Care at the University HospitalWuerzburg, a panel of experts was established in orderto perform the evaluation process. The expert groupconsisted of leading representatives of the EmergencyMedical Services of Wuerzburg, the offices for Emer-gency Medical Services and for Fire Brigade Alerting,the government of Lower Franconia, the emergency pas-toral care, the police forces and the head of the subsec-tion emergency and disaster relief medicine.The project was presented to the local ethic committee

and was exempted from the need of ethical approval.The definition of the quality indicators and operational

characteristics for civil rescue missions during terror at-tacks were picked in a way that allows for a quantitativeand qualitative description, evaluation and assessment ofthese missions. The main focus was based on the rele-vance, the comprehensibility and the measurability of theparameters. These criteria were based on the so calledRUMBA norm, which is an acronym for “relevant”,“understandable”, “measurable” “behavioural” (influencedthrough behaviour) and “achievable”. The process was amixture of the nominal group technique combined withaspects of the broad Delphi method. Through this ap-proach we could integrate the abundant backgroundknowledge and experience of our experts and combine itwith the benefits of group dynamics and discussion.In the first meeting the 14 dedicated members of the

expert group were asked to define quality indicators andoperational characteristics to best describe and evaluaterescue missions during mass killing events. In order toobtain a more general approach a direct relation to theWuerzburg mission should be avoided at that time. Theresult was a list of indicators and characteristics whichwere than judged and adopted by consensus within thegroup. A second meeting took place after two weeks.Each indicator was again critically evaluated within theworking group and the final template was approved byfull consensus [10]. After the quality indicators wereascertained, they were placed in clusters based on im-portant sub-classifications of the emergency mission inorder to allow for a clear and structured arrangementand overview (third meeting). This result was presentedto an independent expert for review and validation.In the presented study, we followed a three-step evalu-

ation process:

1. Systematic data collection according to the qualityindicators and operational characteristics

Wurmb et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:87 of 15

2. Systematic stratification and assessment of the data3. Mission specific prioritisation and definition of the

lessons learned

Primary data of the emergency rescue mission was col-lected and transferred into an evaluation matrix. A threepoint rating system was used for the assessment of the re-sults. For each quality indicator we attempted to define aspecific rating description (e.g. 0 points = not fulfilled, 1point = partially fulfilled, 2 points = fully fulfilled).We undertook a great effort to attribute an individual

grading system to each indicator wherever possible. Itwas impossible to do this in a uniform way as every indi-cator and the corresponding result had its own meaning.For example: in Table 1 “mission related data”, the firstline raises the question at which time it was noticed thatit was a life threatening incident for the rescue services.The result was 6 min after the first emergency call. ThisΔt on its own is not indicative of any consequences.Therefore, we developed the grading system exclusivelyfor this indicator:

2: notification prior to arrival of the first operationalforces (this means early enough to draw securityrelated consequences).1: notification after the arrival of the first operationalforces, no threat for the operational forces (this meansto late but without consequences for the rescue forces).0: threat or damage to the operational forces (thismeans to late with significant and negativeconsequences for the rescue forces).

For some results such an assessment was not reason-able and some results were descriptive values and there-fore the developed rating system was not applicable.(Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13).After the primary data collection and stratification, the

actual evaluation of the terror attack and the formula-tion of the lessons learned started. For prioritisation pur-poses those parameters, which were seen as particularlyrelevant to the terror attack in Wuerzburg, were identi-fied in each cluster by the group of experts.

ResultsAs a result of this process, 158 identified quality indica-tors were categorised into 13 clusters [10]Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 show

the quality indicators and operational characteristics intheir allocated clusters. Some of the quality indicatorswhich were very specific to the German EmergencyMedical Service system have been omitted in this publi-cation in order to accommodate for a more internationalaudience. At the end, 139 quality indicators remainedfor the presentation of the evaluation process.

The quality indicators, the data of the Wuerzburg emer-gency rescue mission and the assessment of the data areshown in Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13.The quality indicators, which have been identified as

most important by the group of experts (by majority opin-ion) for the Wuerzburg emergency rescue mission formedthe basis for the formulation of the lessons learned.

Category: General Characteristics (Table 1)

� Is there a written concept for mass casualtyincidents for the EMS?

� Is there a written and comprehensive concept fordealing with life threatening incidents?

The EMS of Wuerzburg had a regional operationalconcept for mass casualty incidents. The concept was

Table 1 General Characteristics

General Characteristics Data Assessment

Date 2016.07.18 descriptive

Weekday and time of day Monday 09:14 pm descriptive

Bank holiday no descriptive

Weather (rain, snow etc.) 20 °C, cloudy dry descriptive

Place of incident - rural areaor city?

City of Wuerzburg(130.000 inhabitants)

descriptive

Number of hospitals in the area(radius 50 km)

16 descriptive

Number of local trauma centers? 4 descriptive

Number of regional traumacenters?

3 descriptive

Number of national traumacenters?

1 descriptive

Is there a written concept for MassCasualty Incidents for the emergencymedical services in place?

yes See lessonslearned

Is there a written and coherentconcept for dealing with mass killingincidents/life threatening masscasualty incidents

yes See lessonslearned

Total number of casualties 8 descriptive

Number of casualties classifiedas T1/RED in medical triage

4 descriptive

Number of casualties classifiedas T2/YELLOW in medical triage

1 descriptive

Number of casualties classifiedas T3/GREEN in medical triage

1 descriptive

Number of casualties classifiedas T4/BLACK in medical triage

1 descriptive

Number of hospitalised casualties 6 descriptive

Number of casualties deceasedon site

1 (the offender) descriptive

Number of uninjured people whohave been affected by the event

15 descriptive


available in written form and had been taught and prac-tised previously. The concept was principally useful inhandling the situation but it was not specifically outlinedfor life threatening incidents.The Bavarian Ministry of the Interior and the ministry

for Building and Transport had additionally, very

recently (June 2016), published a new concept namedREBEL to deal with life threatening incidents.

Problem IdentifiedThe very short availability of REBEL, meant that theconcept had not been taught and practiced; hence it

Table 2 Mission related data

Mission related data Data Assessment

At what time was it noticed that this was a life threatening incidentfor the rescue services? (Δt from first emergency call to notificationof life threatening situation)

09:20 pmΔt: 6 min

Result: 22: prior to arrival of the first operational forces1: after the arrival of the first operational forces,no threat to the operational forces

0: threat or damage to the operational forces

Did first notification of the incident happen through police, rescueheadquarter or operational forces on scene?

Police headquarter descriptive

Δ t from notification until communication between rescueheadquarter and police headquarter

Δt: 0 min Result: 22: prior to arrival of the first operational forces1: after the arrival of the first operational forces,no threat to the operational forces


Δ t from alarm until successful notification of all operational forcesabout life threatening situation

Δt: 0 min Result: 22: prior to arrival of the first operational forces1: after the arrival of the first operational forces,no threat to the operational forces


Δ t from alarm until arrival on scene of the first operational forces Δt: 7 min Result: 22: within the help period1: outside the help period due to incidentcircumstances

0: outside the help period without justification

Δ t from arrival on scene until first understanding of the situationand report to the rescue headquarter

Δt: 1 min Result: 22: immediate information1: delayed information0: no information

Δ t from arrival of the first operational forces until the firstassessment and tactical decision

unknown

Δ t from arrival of the mission commander until first assessment ofsituation and planning of the mission

Δt: 10 min Result: 22: immediate1: delayed0: no assessment and planning

Δt from first notification of a life threatening situation until threatcessation

Δt: 106 min descriptive

Use of guns?Use of thrusting weapons (knife etc.)?

Knife and axe descriptive

Use of explosive agents i.e. Improvised Explosive Devices? no descriptive

Abuse of vehicles (truck/car)? no descriptive

Chemical, biological, radio-nuclear threats (CBRN) no descriptive

Any other imminent danger? no descriptive

Total time of mission (in minutes) 245 min descriptive

Static situation (no change in circumstances such as mobileoffenders, changing threats and growing number of casualties)?

No descriptive

Dynamic situation (change in circumstances such as mobileoffenders, changing threats and growing number of casualties)?

yes descriptive

Combination of static and dynamic situation? no descriptive

Multisite attack? no descriptive


could not be used during the terror attack and hence theregional mass casualty incident concept was used in-stead. Additionally medical equipment for the care ofpenetrating injury (tourniquet, chest seal etc.) was notavailable at the time of the assault.

Lesson learned 1A harmonised, easy to use and well-trained concept isessential in order to successfully deal with life threaten-ing mass casualty incidents. The REBEL concept hasexisted for over a year now (2016–2017) and the ambu-lances have been equipped with additional material ac-cording to the concept in order to provide adequateprehospital “damage control” care (tourniquets, chestseals, pelvic belts, haemostatic bandages, IO needles andemergency thoracostomy needles). The concept wasadapted and modified to fit the specific regional require-ments around Wuerzburg and the training phase hasbeen completed successfully.

Category: Mission related data (Table 2 )

� When was it noticed that this was a life threateningsituation for the operational forces? (Δ t from firstalarm to notification)

� Δ t from notification until communication betweenmedical rescue control centre and police controlcentre

� Δ t from alarm until successful notification of alloperational forces about life threatening situation

The first communication between the police controlcentre and the medical rescue control centre includedthe word “rampage” and “terror” and hence the situationwas clearly defined from the start. The communicationbetween police and emergency medical service (EMS)worked very well in the initial phase of the mission. Allrelevant information was passed on between the differ-ent services.

Problem identifiedDuring the course of the mission a one sided informa-tion flow between the police control centre and the res-cue control centre was established. Unfortunately thecommunication was uncoordinated and led to a diffu-sion of information as many phone calls involving manydifferent parties were held. Information could not begathered effectively which led to a lack of concise infor-mation, evaluation and situational understanding. Thedrawing of concise consequences and conclusions wereimpossible.

Lesson learned 2Establishment of a high priority communication infra-structure between the police control centre and themedical rescue control centre (“red phone”) is a crucialpoint. This is vital in order to provide a constant flow ofinformation between a defined dispatcher and recipient.This communication is essential not only during the ini-tial phase (early and fast track evaluation of the situationvia this communication channel) but throughout themission. The aim is to provide continuity of informationbetween few well defined individuals in order to allowinformation gathering instead of information dispersal.

Category: Organization of the scene (arrangement of thearea) (Table 4)

� Was there a structured organization of the sceneduring the operation?

� Was the organization of the scene adequate for lifethreatening incidents (e.g. unsafe and safe sectors,safe assembling areas?)

� Did everyone know (police forces and operationalmedical forces) about the organization of the scene?Was the organization of the scene appliedsuccessfully?

Yes – there was a structured organization of the sceneduring the operation.

Problem identifiedBecause of the mobile and dynamic incident scene (run-ning train) and the ambiguous description of the defineddeployment sector, the deployment sector of the EMS

Table 3 Alarm Procedure

Alarm Procedure Data Assessment

Δ t from first emergency calluntil use of buzzword(i.e. terror, rampage, life-threatening situation)

Δt: 4 min Result: 22: immediate1: delayed0: no

Δt from first emergency calluntil first alarm

Δt: 4 min Result: 22: immediate1: delayed0: no

Δ t from first alarm untilrescue forces report operationalreadiness


Δ t from operational readinessuntil arrival of the rescue forceson scene


Was there enough manpowerat the rescue headquarter(dispatch center) at the start ofthe operation

No descriptive

Has the rescue headquarter analarm system of additionalrecruitment in place if needed

yes descriptive

If there was a lack of forces inthe rescue headquarter: Δ t fromfirst notification until full recruitment



was placed within the unsafe area despite the police hav-ing designated a deployment sector within the safe zone.This problem was based on miscommunication and mis-understanding between the police and the EMS ratherthan difficulties with the organization of the scene itselfs.

As a result casualties were treated by the EMS within theunsafe, dangerous zone of the incident with a still uncon-trolled, active perpetrator. Fortunately none of the rescueforces got injured and the treatment of the casualtiescould take place without any delay.

Table 4 Organization of the scene (*distance in meters)

Organization of scene (Arrangement of the area) Data Assessment

Was there a structured organization of the sceneduring the operation?

Yes Result: 11: Yes0: NoSee lessons learned

If so, who coordinated the organization of thescene (police forces and/or rescue forces)?

Rescue Headquarter descriptive

Δ t from first alarm until arrangement of the area Δ t: 0 Minutes Result: 22: prior to arrival of the first operational forces1: after the arrival of the first operationalforces, no threat for the operational forces


What was the arrangement of the area? Yes:Damage sectorDeployment sectorOn–site Command post

descriptive

Was the arrangement of the area adequate forlife threatening incidents (e.g. unsafe and safezones, safe assembling areas)

No, due to the dynamic situation thedeployment (EMS) sector was locatedin the unsafe zone.

Result: 02: adequate1: not adequate, no threat for the operationalforces

0: potential threat or damage to theoperational forces

See lessons learned

Did everyone know (police forces and rescueforces) about the organization of the scene?Was the organization of the scene appliedsuccessfully?

Yes!No: due to ambigous information

See lessons learned

Δ t from first alarm until a deployment sectorwas planned

Δ t: 0 Minutes

Distance (*in meters) between the deploymentsector to the unsafe zone

0 m Result: 01: sufficient0: insufficient

Distance* between the on-site command postto the unsafe zone


Was a triage area established? no

If so - distance* between triage area andunsafe zone? (secured perimeter)

not applicable

Was there an assembling area (casualtygathering point) established

no

If so – distance * between assembling area(casualty gathering point) and unsafe zone?

not applicable

Was there a zone-related stepwise medicaltreatment concept according to the principalsof Tactical Combat Casualty Care (care underfire, tactical field care, tactical evacuation care)established?

No, the full medical care wasprovided in the unsafe area

descriptive

Was an assembly area for uninjured people,who have been affected by the event, established?

yes descriptive

If so - distance* between the assembly area andunsafe zone?



Lesson learned 3A commonly (police and EMS) decided and consentedorganization of the scene and arrangement of the areawas identified as a crucial point for the successful com-pletion of the mission.

� Establishment of a common access route to theincident area used by police, firearm services andemergency medical services.

� Establishment of a common arrangement of the areaespecially a common and safe deployment sector.

� Establishment of a common on-site command post.� The incident area should be divided into an unsafe,

semi - safe and safe zone with different modes ofaction within these zones.

Category: Mission strategy and tactics (Table 5)

� Which strategy i.e. “Clear up the scene”- wasapplied?

� Which tactical plan of action was chosen?

No strategy specifically designed for life threateningincidents was used. To clear up the scene immediatelymeans to rapidly identify the most seriously injured pa-tients and evacuate them towards the designated hospi-tals. This strategy reduces the on-scene time andaugments the safety of the rescue forces. No such strat-egy was developed and trained prior to the event andhence none could be applied.The medical care was based on individual needs and

was based on individual injuries rather than tacticalconsiderations.

Problem identifiedEven though it was known that the incident was a terrorattack the principles of Tactical Combat Medical Care(TCCC) were not used. These principles were neitherwell known nor practiced prior to the incident andhence not part of the routine action pattern of the res-cue forces. Hence, none of these principles were usedduring the Wuerzburg terror attack. In terms of safetyissues for the rescue forces this would have been benefi-cial, looking at the quality of medical care however, therewas no disadvantage for the casualties.

Lesson learned 4In order to allow the application of specific strategiesand tactics in a life threatening mission, these strategies

Table 5 Mission strategy and tactics

Mission strategy and tactics Data Assesment

Which mission strategy i.e. “Clear up the scene”-was applied?

No terror related strategy was applied. A missionstrategy for mass casualty incidents was applied.

See lessons learned

Which tactical plan of action was chosen?For example:Fastest transport to hospitals of the patientswith Triage Category T1/RED?

Basically the mission strategy for mass casualtyincidents was applied. There was an ongoingthreat, so swift evacuation of the patients withtriage category I/RED was the most importanttactical decision

See lessons learned

At what time were tactical consequences drawn? unknown

Who drew them? Subsection Commander of the “subsection damage” Descriptive

Δ t from arrival of the first rescue services onscene until a tactical plan of action was fullyimplemented?

Unknown

Coordinated tactical decisions drawn by police,emergency medical services and fire brigade?

Yes

Table 6 Incident Command System/ Line of Command

Incident Command System/Lineof Command

Data Assessment

Was an incident command systemestablished?

Yes Result: 11: yes0: no

Did the incident commander in chief(medical) have influence on the courseof action during the mission?

Partly Result: 12: complete1: partly0: none (see lessons learned)

Did the command processes workadequately?


Did the incident commander in chief(medical) always have adequateinformation for repeatedre-evaluation and understaning ofthe situation (continuous flux ofreports)?

No Result: 02: always1: sometimes0: never (see lessons learned)

Did the incident commander inchief (medical) have influence onthe course of action during themission

Partly Result: 12: complete1: partly0: none

Did the incident commander in chief(medical) have control of thesubsection commanders?


Was a functioning resourcemanagement established?

Yes Descriptive


and tactics need to be developed and practiced before-hand. Without instructions, knowledge and specifictraining none of the strategies can be used on scene in alife threatening situation. The operational forces need tohave internalised the processes in order to access themeffectively in a high pressure situation such as a lifethreatening mission.

We have formulated the following key points to helppreparing the rescue forces for future incidents:

� Are there comprehensive management plans inplace?

� Are these plans well known and well trained?� Are there common drill and training possibilities?

Table 7 Communication

Communication Data Assesment

Was there a previously defined communication infrastructure between the rescueheadquarter and the police headquarter?

No Result: 01: present0 not present

Which communication system was used? Radio and telephone Descriptive

Was a communication plan established before the mission started? No Result: 01: yes0: no

Was the plan applied? Not applicable

Was there a regular and structured re-evaluation of the situation for the incidentcommander in chief throughout the different mission phases (continuous report flux)

no See lessons learned

If so, where the results recorded in a timely and structured method (mission diary/map of incident site)?

no Result: 01: yes0: no

Was an infrastructure for communication between medical services, police andfire services established?

no See lessons learned

Did police, medical services and fire services communicate regularly andeffectively with each other?

Yes: the subsection commandersNo: The incident commanders in chief

12: yes1: partly0: no

If so, which communication infrastructure was used? Mobile telephone Descriptive

Table 8 Triage

Triage Data Assessment

Was a triage algorithm used? No specific algorithm was used. Result: 02: the trained standardalgorithm

1: any arbitrary algorithm,0: no algorithm

If so, which triage algorithm was used? Not applicableThe standard triage algorithm in Bavaria ismStART. It was not deployed by the rescue forces.

Δ t from arrival of first rescue services on scene until the startof triage?

Unknown 2: immediate1:delayed0: no triage

Who was responsible for the triage? Emergency medical services descriptive

Where life saving measures delivered during the first triage cycle? Yes descriptive

Δ t from arrival of first rescue services on scene and communicationof primary triage result to the rescue headquarter

Δ t: 8 min descriptive

Were casualties treated according to triage priorities? Yes Result: 22: yes, completely1: yes, partly0: no

Were casualties allocated to hospital according to triage priority? Yes Result: 22: yes, completely1: yes, partly0: no


� Are there clear mission goals and strategies?� Is there stockpiling of the equipment and material?� Is this equipment and material readily available?

Category: Incident command system andcommunication (Tables 6, 7)Because of the interconnections between these clustersand different quality indicators it has been decided to il-lustrate them in combination instead of addressing themindividually.

� Did the command processes work adequately?� Did the incident commander in chief (medical)

always have adequate information for repeatedreevaluation and understanding of the situation(continuous flux of reports)?

Table 9 Casualty Care

Casualty Care Data Assessment

Was medical care based on damage control principals? No, there was complete resuscitative careprovided

descriptive

Was there a stepwise care provision according to the different sectors (unsafesector: “Care under fire”; semi-safe sector: “Tactical Field Care”; safe sector:“Tactical Evacuation Care”?

No, the medical care was provided in theunsafe area(due to the circumstances explained above)

descriptive

Were there any delays in medical care due to safety issues such as threats torescuers?

no descriptive

If so, how long did it take until the last casualty had received medical care? descriptive

Δ t from first emergency call until transport of the first casualty with triagecategory T1/RED to hospital


Δ t from first emergency call until transport of the first casualty with triagecategory T2/YELLOW to hospital

Δ t:41 min descriptive

Δ t from first emergency call until transport of the first casualty with triagecategory T3/GREEN to hospital

unknown descriptive

Δ t from first emergency call until arrival of the first patient with category T1/RED in hospital


Δ t from first emergency call until arrival of the first casualty with categoryT2/YELLOW in hospital

unknown descriptive

Δ t from first emergency call until arrival of the first casualty with categoryT3/GREEN in hospital


Δ t from first emergency call until transport of the last casualty withcategoryT1/ RED to hospital


Δ t from first emergency call until transport of the last casualty with categoryT2/YELLOW to hospital

none descriptive

Δ t from first emergency call until transport of the last casualty with categoryT3/GREEN to hospital

none descriptive

Δ t from first emergency call until arrival of the last casualty with categoryT1/RED in hospital


Δ t from first emergency call until arrival of the last casualty with categoryT2/YELLOW in hospital

none descriptive

Δ t from first emergency call until arrival of the last casualty with categoryT3/GREEN in hospital

none descriptive

Δ t from first emergency call until last casualty found Δ t:36 min descriptive

Δ t from first emergency call until identification of all casualties Δ t:106 min descriptive

Table 10 Documentation

Documentation Data Assessment

How were the triageresults documented?

EMS (Emergency medicalservice) Protocol

descriptive

How was the casualtyregistration documented?

Computer basedprotocol

descriptive

Δ t from first alarm untilfull identification ofcasualties and involvedparties documented

Δ t: 106 min

Were injury reportcards used?

Yes Results: 02: for all patients1: some patients0: No cards wereused

Was the documentationcomplete?

No Results: 01: complete0: incomplete


� Did the incident commander in chief (medical) havecontrol of the subsection commanders?

� Was there a regular and structured re-evaluation ofthe situation for the incident commander in chiefthroughout the different mission phases?

� Was an infrastructure for communication betweenmedical services, police and fire servicesestablished?

Functioning command processes could only partiallybe established. There were functioning command pro-cesses between the commanders of the mission sub-sectors but the on-site incident commander in chiefdid not have adequate information in order to repeat-edly re-evaluate the situation. There was no continu-ous flux of reports from the subsector commanders(sector danger and sector mission) to the on-site

Table 11 Rescue Forces

Rescue Forces Data Assessment

Was there an adequate casualties / operational force ratio at anypoint during the mission

yes Result: 11: yes0: no

If so, was this adequate ratio lost again at some point (too manyrescue forces)?

Yes, many of the rescue service forces were kept inreserve as a multisite attack was initially anticipated

Δ t from first emergency call until adequate ratio was reached Δ t: 26 min Result: 22: fast1: with delay0: never

Were staff reservoirs built up? yes

Was a structured replacement of the operational forces necessary? no descriptive

Were the operational forces in concrete danger at any point? yes descriptive

Were members of the operational forces injured during the mission no Result: 11: no0: yes

Table 12 Hospitals

Hospitals Data Assessment

Δ t from first notification/alerting of the hospitals until arrival of thefirst casualty

Hospital 1: Δ t = 36 minHospital 2: Δ t = 36 minHospital 1: Δ t = 36 min

descriptive

Do the hospitals have plans in place? Hospital 1: yesHospital 2: yesHospital 1: yes

Result: 22: all1: partly0: none

Were the emergency plans activated? Hospital 1: noHospital 2: noHospital 1: no

descriptive

Were the emergency plans successfully applied? not applicable

When was the rescue headquarter informed about the capacity ofthe hospitals to receive and treat casualties?Δ t from first notification until capacity information

Hospital 1: 6 minHospital 2: 5 minHospital 3: 5 min

Result: 22: immediately1: delayed0: never

Ratio between announced to actually delivered causalities Hospital 1: 4/4Hospital 2: 1/1Hospital 3: 1/1

descriptive

Adequate allocation and distribution of causalities? yes Result: 22: yes - all1: yes - partly0: none

Number of self-referred casualties zero descriptive

Did the hospitals have a strategy in place to deal with lifethreatening mass casualty incidents?

Hospital 1: noHospital 2: noHospital 3: no

Result: 01: yes0: no


incident commander in chief. There was no infra-structure for communication between EMS and thepolice.

Problem IdentifiedThere was an infrastructure for communication betweenthe EMS while this infrastructure was missing for thecommunication between police forces and EMS.There was effective communication between the sub-

sector commanders while the communication betweenthe incident commander in chief and the subsectioncommanders was incomplete.

Lesson learned 5A successful mission tactic requires continuous flux ofreports to the on-site command post. This includes “upto date” situational information from all different subsectors of the mission as well as reliable informationabout the safety situation at the incident site. A prede-fined and common communication infrastructure for alloperational forces is a crucial point for the successfulcompletion of the mission. Use of the same nomencla-ture between police services and the EMS is a crucialpoint.Hospitals play a vital role in the treatment of patients

in the case of terrorist attacks. They are a key element inorder to evacuate patients from an unsafe environmenttowards definitive medical treatment. Therefore hospi-tals need to be involved in the medical response fromthe very beginning.

DiscussionThis work describes the systematic evaluation of and for-mulates the lessons learned from a civil rescue missionduring a terror attack in Germany.Applying the described three step evaluation process

allowed for an objective, systematic and well-structureddescription of the rescue mission. The combination of

expert input into prioritisation of various qualityindicators and the definition of the lessons learnedbased on those indicators allowed for a very precise andeffective evaluation of the Wuerzburg emergencyrescue mission.On the basis of the template of Fattah et al. [8] the res-

cue mission during the terror attack in Utoja, Norwaywas evaluated and reported systematically (http://major-incidentreporting.net/wp-content/uploads/2016/08/utoya.pdf). The key lessons are described as follows:

� Lack of a common triage system� Delayed access to patients due to security issues� Communication breakdown

Solutions for these lessons learned were:

� The establishment of a national triage system.� A better system for cooperating with the police

forces in order to get quicker access to casualties.� The improvement of the communication systems.

The close cooperation between police forces and res-cue forces in particular, is a key lesson we also definedfrom our results. Our findings also confirm the need fora secured and coordinated communication.Two recent publications report specific indicators as

quality control tools for major incidents. Nilsson et al.defined a set of 11 performance indicators qualifying theperformance of the initial medical command and controlin major incidents [11]. Radestad et al. presented key in-dicators for disaster medical response defined through aDelphi study [12]. Both classification systems are notspecific for terror attacks. There is a recent systematicliterature review for prehospital management of masscasualty civilian shootings published by Turner et al. in2016 [13]. None of the included reports was based on asystematic evaluation approach using quality or

Table 13 Psychological emergency care

Psychosocial emergency care Data Assessment

Δ t from first alarm to deployment of the psychosocial emergency services Δ t: 7 min Result: 22: early1: late0: never

Was the psychosocial emergency care coordinated through police and medical service? yes descriptive

Was psychosocial emergency care offered during the days after the incident? yes descriptive

Was psychosocial emergency care offered to rescue forces during the days after the incident? yes descriptive

Was psychosocial emergency care offered to affected people during the days after the incident? yes descriptive

Was there a felt/real hazard to the rescue forces at any point? yes descriptive

How many casualties did receive psychosocial support? none descriptive

How many uninjured affected people did receive psychosocial support? 20 descriptive

How many members of the rescue forces did receive psychosocial support? 67 descriptive


http://majorincidentreporting.net/wp-content/uploads/2016/08/utoya.pdf



performance indicators. The authors of the systematicreview stated that a uniform and comprehensive report-ing of such events is required [13].Fattah et al. published a systematic review of the litera-

ture in 2013 [7]. The authors studied the availability oftemplates suitable for the report of prehospital major in-cidents. They identified 10 templates published in the in-cluded literature. DISAST-CIR was one of the describedtemplates in this review, which is a standardized tem-plate used in Israel and was published by Leiba et al. [9].Fatah et al. concluded in their systematic review thatsome limitations are present in all of the templates butthat the identified templates may serve as a basis for de-signing a template that exclusively targets prehospitalcare in major incidents [7]. Such a template was de-signed and published by Fatah et al. in 2014 [8]. The au-thors defined 48 different variables (with 293sub-variables) in 6 clusters in order to document and de-scribe rescue missions during mass casualty incidents[8]. After the introduction and the subsequent applica-tion of the template to several incidents, some limita-tions were noted by Fattah et al. [14]. Consequently, theauthors revised the template, which is now available lessdetailed and more user-friendly [6]. As we explainedabove we designed a new template for the evaluation ofthe Wuerzburg terror attack in order to particularly con-centrate on the terror related aspects of the attack.Nevertheless we fully support the goals of Fatah et al.and other authors [5, 6, 13] to significantly increase andimprove the disposition to systematically report andevaluate major incidents but also mass killing events. Inthe future a close international collaboration betweenthe different researchers and caregivers dealing with theissue might help to find the best template in order toimprove these missions outcome.The evaluation process of the Wuerzburg terror attack

and the formulated lessons learned are seen as part of anational and international process to improve the man-agement of life threatening mass casualty incidents.The German Society of Anaesthetics and Intensive

Care Medicine (DGAI) has, in collaboration with leadingrepresentatives from police, fire brigades, emergencyphysicians, emergency medical services, hospital servicesand politics identified systemic issues related to missionsduring life threatening mass incidents. They have fur-thermore developed concrete solutions [15].The German Society of Trauma and Orthopaedics

have developed a course concept (Terror and DisasterSurgical Care) with the help of the military, which isnow offered and trained on a national level in order toimplement the principles of Tactical Abbreviated Surgi-cal Care [16].There are multiple international publications about

the terror attacks in France and their consequences. One

specific publication addresses a few points which weredeemed particularly important [3]. These points were:

� Management of Uncertainties� Management of Victims� Management of Teams� Communication

Especially the communication topic was very importantin the definition of our lessons learned. So we concludedthat a predefined and common communication infrastruc-ture (including redundancy) for all operational forces is acrucial point for successful completion of the mission.Carli et al. have recently published the most important

lessons from the most recent terror attacks in France [4].This publication did not only identify the weaknesses andproblems but also described their solutions and currentimplementation stages of these suggested solutions.In this, the French group of experts have proven great

advancement and their results can be seen as role modelfor other countries having to deal with terror.The most important weaknesses and problems are

summarised below:

� The handling of war weapon injuries� The implementation of the preclinical concept� The handling of trauma in children� The reaction to chemical weapons� The assault on hospitals� Medical treatment “Care under fire”� Triage in hospital� Terror attacks in rural areas� The casualty identification approach� Psychosocial emergency care provision

Carli states important points which have not played a majorrole in our evaluation process. This mainly concerns a highnumber of injured children, attack with chemical weaponsand the casualty identification process. The integration of thelessons learned into the education of medical students isalso a very important task mentioned by Carli et al. [4].

LimitationsNo standardised Delphi method was used in the ascer-tainment of the quality indicators. The standardised Del-phi method was rejected as the most importantcharacteristic of it is the anonymity of the experts [10].This could and should not have been preserved in thisstudy as their participation during the event was one ofthe main criteria why the experts were chosen for theexpert panel in the first place.The results of our analysis include specific elements

which are based on the regional characteristics of theGerman/ Bavarian emergency medical service (EMS). It


is important to mention that both the police as well asthe ambulance services in Germany are under the directcontrol of the states. They therefore differ between the16 different German states, which makes the implemen-tation of a national concept extremely difficult and re-duces the comparability to other European countries.The quality indicators however are so generally formu-lated, that - in our opinion - they could serve as a tem-plate for evaluation of life threatening mass casualtyincidents in any other international EMS system aftercountry specific adaptation.The event that motivated the formulation of the qual-

ity indicators and the following evaluation process wasof limited scale and the number of casualties during therescue mission was low, however we are convinced thatthe experiences and the resulting analysis according toquality indicators can be easily applied to mass killingincidents with a much higher number of casualties.Furthermore the presented evaluation does not include

biological, chemical or radio-nuclear threats. The re-sponse and the preparation for such events needs furtherdetailed evaluation and planning.Based on our data and according to the continuous

evaluation process of the last years [4, 5, 8, 15–19] wehave formulated the following set of measures for themanagement of mass killing incidents (without re-spect to biological, chemical or radio-nuclear threats).

“Response bundle”

– High priority communication between the policecontrol center and the rescue control center viadefined communication channels for the bestunderstanding of the situation.

– Immediate definition of a coordinated andharmonised course of action by police forces and allother rescue services.

– For the first responders: Give immediate report tothe control centre

– Arrangement of the area and management of thescene – definition and communication of the unsafezone, definition and communication of casualtycollection points, triage area (semi-safe zone) andsafe treatment area (safe zone)

– Establishment of command and control structures– Secure Communication– Early Involvement of hospitals

Police Forces:

– Immediate threat diffusion– Immediate estimation and communication of

expected casualty numbers to the rescue forces

– Start casualty treatment and evacuation from theunsafe zone to the semi-safe and safe zones - act asevacuation flow accelerator

Rescue forces:

– Establishment of triage and treatment area in thesemi-safe zone

– Fast triage– Immediate treatment of potentially survivable life-

threatening injuries (exsanguination, airway obstruc-tion, tension pneumothorax) during initialresuscitation

– Identification of casualties with life-threatening non-controllable bleeding

– Prioritised and immediate transport of those“Priority 1” patients to nearby hospitals

“Preparedness bundle”

– Establishment of common (police and rescue forces)sense about mission goals

– Usage of a common language– Common drill and training– Predefinition of secured communication channels– Stockpiling of medical equipment to treat

penetrating bleeding injuries– Stockpiling of transport equipment to maintain

evacuation flow– Secure communication technologies– Prepare for uncommon threats (e.g. biological and

chemical weapons)– Prepare for children in mass casualty incidents

A major issue for preparation to mass killing incidentsis training and education. The most useful approachwould be a multidisciplinary curriculum. Based on ourresults we would recommend that such a curriculumshould include these basic points:

– Development of a common sense (police and rescueforces) about mission goals

– Definition of mission goals and strategy– Managing the scene– Command and Control structures– Communication training between different

disciplines– Basic knowledge and understanding of different

mission tactics– Basic skills-training for the treatment of life threat-

ening bleeding injuries– Managing the evacuation flow


ConclusionThis work describes the systematic evaluation of the res-cue mission during a terror attack according to definedquality indicators. The aim of this approach is to allowfor a coherent and homogenous presentation and evalu-ation of rescue missions during terror attacks. As thetemplate is currently applied for the evaluation and re-port of another mass killing incident in Germany itmight also be helpful to compare different missions witheach other. In the future a close international collabor-ation might help to find the best database to report andevaluate major incidents but also mass killing events. Intimes where terror attacks and mass casualty incidentshave become more common we should all work togetherto support the goal – to significantly increase and im-prove the available possibilities to systematically reportand evaluate mass killing events and to learn from theresults in order to improve these missions outcome.

FundingThis publication was funded by the German Research Foundation (DFG) andthe University of Wuerzburg in the funding programme Open AccessPublishing.

Availability of data and materialsAll data generated or analysed during this study are included in thispublished article.

Authors’ contributionsTW: Conception and design of the Work. Analysis and Interpretation of thedata, drafting of the work. Final approval of the work. First author andcorresponding author. Agrees for all aspects in the work. TW is theguarantor. NS: Conception of the work, drafting the work, final approval,agrees for all aspects in the work. PJ: Conception and design of the Work.Analysis and interpretation of the data. Revising the work critically. Agrees forall aspects in the work. SD: Conception of the work. Analysis andinterpretation of the data. Revising the work critically. Agrees for all aspectsin the work. Commander in chief during the rescue mission. RS: Conceptionof the work. Analysis and interpretation of the data. Revising the workcritically. Agrees for all aspects in the work. Medical Commander in chiefduring the rescue mission. TJ: Conception of the work. Analysis andinterpretation of the data. Revising the work critically. Agrees for all aspectsin the work. Emergency physician on scene during the rescue mission. UK:Conception of the work. Analysis and Interpretation of the data. Revising thework critically. Agrees for all aspects in the work. Subsection Commander inchief during the rescue mission. JG: Conception of the work. Analysis andinterpretation of the data. Revising the work critically. Agrees for all aspectsin the work. Subsection Commander in chief during the rescue mission. GM:Conception and design of the work. Collection, analysis and interpretation ofthe data. Technical design of the data collection. Revising the work critically.Agrees for all aspects in the work. JM: Conception and design of the work.Collection, analysis and interpretation of the data. Revising the work critically.Agrees for all aspects in the work. Coordinator in chief of the Rescue ControlCentre during the mission. MK: Conception and design of the work. Collection,analysis and interpretation of the data. Revising the work critically. Agrees for allaspects in the work. SS: Conception and design of the work. Analysis andinterpretation of the data. Technical design of the data collection. Revising thework critically. Agrees for all aspects in the work. Subsection Commander inchief during the rescue mission. UW: Conception and design of the work.Analysis and interpretation of the data. Revising the work critically. Agrees for allaspects in the work. JH: Definition of the lessons learned. Revising the workcritically, Agrees for all aspects of the work. NR: Design of the work. Analysis andinterpretation of the data. Revising the work critically. Agrees for all aspects inthe work. MH: External Expert, Revising the work critically. Agrees for all aspectsin the work. All authors read and approved the final manuscript.

Ethics approval and consent to participateThe project was presented to the local ethic committee of the University ofWuerzburg and was exempted from the need of ethical approval. ReferenceNumber: 20170123 01. No human participants, human data or human tissueswere included.

Consent for publicationThe manuscript does not include individual person’s data.

Competing interestAll authors declare that there are no competing interests. There was no supportfrom any organization for the submitted work; no financial relationships withany organizations that might have an interest in the submitted work in theprevious three years, no other relationships or activities that could appear tohave influenced the submitted work.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Subsection Emergency and Disaster Relief Medicine, Department ofAnaesthesia and Critical Care, University Hospital of Wuerzburg,Oberdürrbacherstrasse 6, 97080 Würzburg, Germany. 2Department ofAnaesthesia and Critical Care, University Hospital of Wuerzburg, Wuerzburg,Germany. 3Emergency Medical Services and firebrigade alerting for thecounties of Kitzingen, Main-Spessart and the city of Wuerzburg, Wuerzburg,Germany. 4Emergency Medical Service of the Bavarian Red Cross, Würzburg,Germany. 5Medical Department, Government of Lower Franconia,Wuerzburg, Germany. 6Emergency Medical Service of the Maltese Cross,Wuerzburg, Germany. 7The Johanniter Rescue Emergency Services,Wuerzburg, Germany. 8Fire and Rescue Integrated Control Centre Wuerzburg,Wuerzburg, Germany. 9Medical Head of the Emergency Medical Services ofLower Fraconia, Wuerzburg, Germany. 10Head of emergency pastoral care inthe diocese of Würzburg, Wuerzburg, Germany. 11Department of dangerprevention and police operation by the police department of LowerFranconia (Chief Police Officer i.R.), Würzburg, Wuerzburg, Germany.12Department of Anaesthesiology and Intensive Care Medicine, SectionEmergency Medicine, Federal Armed Forces Medical Hospital, Ulm, Germany.

Received: 2 July 2018 Accepted: 2 October 2018

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